Wednesday, February 28, 2007

How medical students learn the pelvic exam

In the past medical students performed exams on anesthetized patients waiting for surgery, sometimes without their knowledge or consent, a practice now condemned. But the backlash from that controversy resulted in today's medical students doing many fewer exams during training than before, Dr. Adam J. Wolfberg, a fellow in maternal-fetal medicine at Tufts-New England Medical Center, writes in a Pespective in tomorrow's New England Journal of Medicine.

"We have an absolute obligation to provide our patients with outstanding compassionate care and it requires that we respect their privacy and their wishes regarding whether they want to participate in the process," he said in an interview. "But we also have a responsibility to make sure that medical school graduates are competent at doing a pelvic exam."

Medical schools now hire volunteers who are typically paid about $200 a session to allow students to examine the cervix, ovaries and uterus. The women also teach, guiding the students as they proceed with the exam.

"They tell them if something hurts and also explain to the medical students how to communicate during an exam that can be embarrassing for the patients and for the medical students, " Wolfberg said.

The next step is for medical students to perform the exams on patients who have agreed to be part of the teaching process.

Dr. Steven Ralston, associate professor of obstetrics and gynecology at Tufts, said in an interview that the pelvic exam is different from other diagnostic procedures and that it requires sensitivity when asking a patient's consent.

"There is a much greater degree of intimacy involved," he said. "The vulnerability is much greater than any other thing we do in medicine."

Third-year student Eva Christensen said learning first with a paid volunteer helped remove some of the awkwardness of first attempts. With patients she always identifies herself as a medical student and works with a physician at her side.

"The most important thing to me is to communicate to the patient, to tell them what they will feel," she said. "It is critical for patients to be informed and to be comfortable."